Sodium Bicarbonate Framing
Objective: Sodium bicarbonate is not for every cardiac arrest. Use it for the poisoning and high-potassium pathways the protocol names. The card has the amount. This site does not list milliequivalents.
Why this matters
Sodium bicarbonate is not for every cardiac arrest. Routine use is not recommended. Giving it only to feel like you are doing something is not a reason.
It still belongs on the poisoning and high-potassium pathways the protocol names. The card has the amount. This site does not list milliequivalents.
- Do not open bicarbonate because the arrest is going poorly.
- A tricyclic antidepressant, or another sodium-channel blocker, with a wide QRS is a classic protocol use. You still manage the airway, and you still use a benzodiazepine for seizures.
- Bicarbonate precipitates with calcium. Flush the line.
Clinical sequence
- Do not open bicarbonate because the arrest is going poorly. High-quality CPR, defibrillation, epinephrine timing, and reversible causes still come first in an undifferentiated arrest.
- Use it when the poisoning or high-potassium protocol actually names it. A tricyclic or other sodium-channel-blocker overdose with a wide QRS is a classic picture. You still manage the airway. You still go to the hospital. You still use a benzodiazepine for seizures.
- Flush between calcium and bicarbonate. They form a precipitate. Do not mix them in one syringe.
Teaching points
- Not routine in arrest. It is not a drug you give just to be doing something.
- Sodium-channel blockade, the tricyclic teaching picture: a wide QRS and an unstable patient. Bicarbonate is a common protocol step. This site does not list milliequivalents.
- High potassium: bicarbonate is a possible shift drug if the patient is acidotic and the protocol names it. It is not a substitute for calcium when the ECG is toxic.
- Crush injury or a long time down may appear on some protocols. Follow yours.
Common errors
- Bicarbonate in every PEA arrest.
- The same line as calcium.
- Bicarbonate instead of an airway in a seizing tricyclic overdose.
Practice
One-minute check
With a partner: (1) asystole for 15 minutes, and no poisoning story; (2) an empty tricyclic bottle, a wide QRS, hypotension, and still a pulse. Bicarbonate yes or no, and why.
Related: Toxidromes, Calcium.
Sources & Further Study
Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.
- NASEMSO National Model EMS Clinical Guidelines (2022) — U.S. EMS model language. Your protocol still decides.
- AHA 2025 Part 9: Adult ALS — Routine bicarbonate is not recommended in cardiac arrest.
- AHA 2025 Part 10 — Selected toxicologic uses remain protocol-based.
Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.
Check Your Understanding
Questions drawn only from this lesson. After you check, the key is highlighted. Education practice — not a certification exam.